Factors associated with infectious diseases fellowship academic success

ABSTRACT Background A multitude of factors are considered in an infectious disease (ID) training program’s meticulous selection process of ID fellows but their correlation to pre and in-fellowship academic success as well as post-fellowship academic success and short-term outcomes is poorly understood. Our goal was to investigate factors associated with subsequent academic success in fellowship as well as post-fellowship short-term outcomes. Methods In 2022, we retrospectively analyzed deidentified academic records from 39 graduates of the Mayo Clinic Rochester ID Fellowship Program (1 July 2013- 30 June 2022). Data abstracted included demographics, degrees, honor society membership, visa/citizenship status, medical school, residency training program, United States Medical Licensure Exam (USMLE) scores, letters of recommendation, in-training examination (ITE) scores, fellowship track, academic rank, career choice, number of honors, awards, and abstracts/publications prior to fellowship, during training, and within 2 years of graduation. Results Younger fellows had higher USMLE step 1 scores, pre and in-fellowship scholarly productivity, and higher ITE performance. Female fellows had significantly higher USMLE step 3 scores. Prior research experience translated to greater in-fellowship scholarly productivity. Higher USMLE scores were associated with higher ID ITE performance during multiple years of fellowship, but USMLE step 2 clinical knowledge and 3 scores were associated with higher pre and in-fellowship scholarly productivity and receiving an award during fellowship. The USMLE step 1 score did not correlate with fellowship performance beyond year 1 and 2 ITE scores. Conclusions Multiple aspects of a prospective fellow’s application must be considered as part of a holistic review process for fellowship selection. USMLE step 2 CK and 3 scores may predict fellowship performance across multiple domains.


Background
Dedicated subspecialty training in Infectious Diseases (ID) is designed to provide a comprehensive experience in clinical practice, research, and education to allow graduates to practice independently in a variety of settings.ID physicians can practice in academic medical centers, where in addition to clinical practice, there is an emphasis on scholarly productivity and medical education of learners, or in community or private practice, where positions tend to be more clinically oriented.Depending on the individual's career interest, fellows may seek training in an academic or clinical fellowship training program.Most of the ID fellowship training programs in the US offer two years of intensive clinical training, while some programs offer an additional year of studies focused on a career as a physician scientist or an ID subspecialist (e.g., transplant ID).In 2023, there were 189 certified ID fellowship training programs in the United States, and the majority offer two years of clinical training at academic medical centers.These ID fellowship programs interviewed prospective applicants to fill 450 certified fellowship positions through the National Resident Matching Program (NRMP), in an 'all-in' match on a yearly basis.The application, interview, and ranking process is similar to prerequisite Internal Medicine (IM) residency training [1].
As part of this process, ID fellowship selection committees are tasked with comprehensively reviewing multiple aspects of a prospective fellow's application including pre-medical, medical school and IM residency performance, United States Medical Licensing Examination (USMLE) step 1, 2 clinical knowledge (CK), and 3 scores, program director and faculty letters of recommendation, personal statement, as well as extracurricular, volunteer, and scholarly activities.Following this rigorous initial holistic review, candidates are selected to interview for available positions through the NRMP match.During the interview, the selection committee will assess the applicant's career goals as well as the overall fit into the program.At the conclusion of the interview process, programs' rank order lists of applicants are created after taking into consideration the preinterview application strength, interview interactions with program director and selection committee members, faculty, staff, and current trainees, as well as institutional fit (to ensure that their career goals will be supported by the program).This list is then submitted to the NRMP to facilitate the match process.
Despite this approach to the review of prospective fellows' applications, selection of interview candidates and subsequent creation of a program rank order list, the factors taken into consideration in the selection and ranking of applicants and their association with academic success have not been well characterized.
For the purpose of this study, academic success was measured by performance during standardized testing, scholarly productivity, career choices, and academic productivity within 2 years of graduation.Factors associated with fellowship academic success have been identified in larger IM subspecialties, but not for ID fellowships [2,3].The comparatively lower number of ID fellows relative to other IM subspecialty training programs, such as gastroenterology, cardiology, and hematology/oncology may have limited the feasibility of such a study.Additionally, this is further compounded by historically lower fill rates of ID fellowship programs over the years [4][5][6].In 2023, about half (50.8%) of the ID fellowship training programs completely filled their certified positions, while the rest (49.2%) have at least one unfilled position; only 303 of the 450 (67.3%) certified positions were filled successfully through the NRMP [1].
Given the paucity of data surrounding factors associated with fellowship academic success in the current literature, we sought to perform a retrospective review of trainees to identify factors associated with academic success among ID fellows in our program.

Methods
The Following Mayo Clinic Institutional Review Board approval, we performed a retrospective cohort study of graduates of the Mayo Clinic Rochester ID fellowship program over a decade-long period between 2013 and 2022 by reviewing de-identified trainee academic records.During this study period, the number of ID fellows increased from 3 per year to 6per year [1].Prior to data collection and analysis, the study protocol was reviewed by the Educational Research Committee of the Mayo Clinic Institutional Review Board and found to be in compliance with the learners as research subjects policy at Mayo Clinic.Data abstracted included demographics, medical degree, additional advanced degrees, honor society membership, visa/citizenship status, medical school, residency training program type and size, USMLE step 1, 2CK, and 3 scores, letter of recommendation with note of a top qualifier, in-training examination (ITE) scores, fellowship training track, academic rank at graduation, career choice, number of abstracts, honors, awards, and publications prior to matriculation into fellowship, during training and within 2 years of graduation.
Publication data were collected following a search of indexed publications on PubMed accounting for name changes of fellows in addition to a review of an internal Mayo Clinic database of scholarly activity including peer-reviewed articles, abstracts, editorials, letters, commentaries, and book chapters.Data on awards were obtained from de-identified academic records as outlined above at the following levels: divisional awards given to fellows in recognition of clinical performance or scholarly productivity, awards given at the institutional level (for work related to clinical care, safety, research), and national awards (including travel grants that recognize abstracts of distinction).The Geraci Award is a divisional award that is voted on by faculty and is given to one or two graduating fellows each year in recognition of excellent performance in clinical care, education, and research during ID fellowship.
Data in the accompanying tables are displayed as either frequency (%) for nominal variables or median (range) for continuous variables.Spearman's correlations were used to test associations between two continuous variables.Associations between continuous predictors and binary outcomes were tested by univariable logistic regression.Two-sided t tests or analysis of variance models were used to test associations between binary or multinominal predictors, respectively, and continuous outcomes.Fisher's exact test was used to test associations between two binary variables.All analyses were performed on RStudio statistical software, version 2022.07.1.554(RStudio Team, PBC, Boston, Massachusetts, United States).

Results
Over the study time frame, there were thirty-nine ID fellowship program graduates with the accompanying characteristics (Table 1).Twenty-one fellows were male (53.8%).The median age at the beginning of ID fellowship was 31 years (range 26-42).Sixteen (41%) trainees were United States citizens, whereas fourteen fellows held a J1 visa (35.9%), 8 held a H1b visa (20.5%) and one fellow (2.6%) was a permanent United States resident.Twenty-five fellows (64.1%) were international medical graduates.Median USMLE step 1, 2 CK, and 3 scores were 240, 246, and 233, respectively.Twenty-three fellows (59%) completed IM residency training at an academic medical center and 33% of trainees attended a residency program with more than fifty trainees per residency class.Five fellows (12.8%) completed additional training as a Chief Medical Resident.The median number of abstracts and publications prior to fellowship were 5 and 3, respectively.
During training, the median number of abstracts was 6 (range, 1-21) and the median number of publications was 6 (range, 0-54).The most common fellowship tracks were the traditional clinician scholar followed by intensive care (paired with antimicrobial stewardship and infection control), transplant and immunocompromised host and research tracks (Table 2).Thirty-six (92.6%) of fellows received an award during training and 97.4% of graduates took ID consultant positions at academic institutions.Additional cohort characteristics are available in Tables 1 and 2.

Factors associated with pre-fellowship performance
Female gender was associated with a higher USMLE step 3 score (p = .041),while a younger age was associated with a higher USMLE step 1 score and a higher number of pre-fellowship publications (p = .021and .032,respectively).Further, a higher USMLE step 2 score was associated with a higher number of pre-fellowship publications (p = .031).The results of this analysis of the effect of demographic factors and pre-fellowship variables are shown in Table 3.

Factors associated with performance during ID fellowship
The results of the analysis of associations between prefellowship and in-fellowship variables are displayed in Table 4.A younger age was found to be associated with higher year 1 and year 2 ITE scores (p = .027and .025,respectively) and higher number of publications during fellowship (p = .005).Graduating from an academic/ university-based residency program was associated with higher likelihood of receiving the Geraci award  (p = .037),while a higher number of pre-fellowship abstracts were associated with higher numbers of abstracts and publications during fellowship (p = .026and .002respectively).
A higher USMLE step 1 score was associated with higher year 1 and year 2 ITE scores, whereas a higher USMLE step 2 score was associated with higher ITE scores across all 3 years and higher likelihood to receive the Geraci award (Table 4).Additionally, USMLE step 3 performance was associated with higher year 1 and year 2 ITE scores, a higher number of publications during fellowship, higher likelihood of receiving an award during fellowship, and higher likelihood to receive the Geraci award (Table 4).

Factors associated with post-fellowship outcomes
With regard to the association of in-fellowship variables and outcomes data, fellows who received an award during fellowship had higher numbers of publications both during fellowship and during their first two years after fellowship graduation (p = < .001and .002,respectively).Post-hoc pairwise analysis showed those appointed to the academic rank of Assistant Professor of Medicine had higher numbers of abstracts and publications during fellowship as compared to those appointed to instructor of medicine rank (Table 5).In addition, years 1-3 ITE performance as well as the receipt of the Geraci award were associated with a higher score on the ABIM ID Certification Exam (Table 5).

Discussion
The benefit of ID subspecialty evaluation has previously been highlighted through studies demonstrating improved survival and outcomes in patients with blood stream infections and drugresistant organisms [7-9].The importance of ID expertise in routine clinical care and ongoing public health efforts has been further accentuated throughout the COVID-19 pandemic and moving forward, the need for subspecialty training in ID continues to be of the utmost importance for ongoing pandemic preparedness [10].Given the ongoing low fill rates and the challenges with  recruiting trainees to the ID specialty, it is imperative to develop a deeper understanding of how fellows can be most successful academically throughout their training experience [1,4].
Prior studies have characterized factors associated with academic success and career choice within hematology and oncology fellowship training, which concur with our observed correlations between USMLE examination and ITE performance but were not predictive of academic productivity.In contrast, we observed that age and gender were associated with ITE performance among our ID fellows [2].Hematology and oncology fellows who were non-US citizens and/or international medical graduates (IMGs) were found to be more academically productive, but this was not seen in our cohort.These differences in observations highlight the need to assess factors that are unique or associated with specific training programs.To our knowledge, our study is the first study of its kind to identify factors associated with ID fellowship academic success, taking into consideration data provided during the fellowship application process and the association on subsequent fellowship achievement and academic success.
Several pre-fellowship variables were significantly correlated with academic performance during ID fellowship training.Having a prior research experience translated to significantly higher in-fellowship scholarly productivity.It is possible that satisfaction in research experience ignited the passion among these ID fellows to develop a career as a clinician investigator or scholar.There was also association among scores on pre-fellowship standardized examinations (USMLE) and subsequent performance infellowship examinations (ITE).In our study, higher USMLE scores were associated with higher performance on the ID ITE during multiple years of fellowship, confirming findings from prior studies demonstrating this association [11].Beyond their association with ITE performance, higher USMLE step 2 CK and 3 scores were also associated with higher pre and in-fellowship scholarly productivity as well as likelihood of receiving an award during fellowship.Indeed, the collection of these objective measures could reflect the multifaceted excellence of fellows that eventually gets recognized with these awards during fellowship, particularly the Geraci Award.Interestingly, in contrast, USMLE step 1 score did not significantly correlate with fellowship performance beyond the year 1 and 2 ITE scores.Similar correlations of USMLE examination performance to ID ITE equivalents have been observed across other non-IM specialties including orthopedic surgery, plastic surgery, anesthesiology, emergency medicine, and obstetrics and gynecology residencies [12][13][14][15][16].
Applications of this work include its potential to guide both ID fellowship selection committees and prospective applicants through subsequent application cycles [1].The association between prefellowship research experience and in-fellowship research productivity may be useful for training programs that are geared towards recruiting and training the academic clinician-scientists, the importance of which cannot be overstated, as they are often relied upon to move the field with their cutting-edge scientific investigations.The association between USMLE step 2 CK and 3 performance and in-fellowship success variables across multiple domains suggests that these examinations may serve as additional tools for selection committees when considering a candidate's potential for in-fellowship academic success.The importance of the USMLE step 2 CK and 3 examinations may be further underscored in future application cycles as the USMLE step 1 recently transitioned to a pass/fail examination in 2022.While unique to our study, previous research outside of ID to evaluate the utility of USMLE step 2 CK on prediction of training performance has been mixed.This examination has previously been shown to be a predictor of multimodal performance during IM residency in the ambulatory setting, whereas this examination was not found to be a reliable predictor American Board of Neurological Surgery written exam performance [17,18].
Limitations of this study include its generalizability across ID fellowship programs.First, this retrospective study was conducted at a large academic medical center in the Midwestern United States.Secondly, the Mayo Clinic Rochester ID Fellowship Program is a three-year program for all its general ID fellows, providing them with the opportunity for academic advancement.Our results may therefore reflect programs with a similar length of training.Admittedly, this is not the same structure for most ID fellowship programs in the country, where 2 years is the standard duration of training for eligibility for certification by the ABIM.Accordingly, measures of scholarly productivity in this study may not be applicable to most two-year clinical training programs.However, there are other findings that may be pertinent to all programs, such as the strong association among standardized examinations, and other factors that predict excellence in clinical skills, research, and education (as measured by the Geraci award in this program).Future investigations may be targeted towards elucidating the effect of pre and in-fellowship variables on infellowship clinical performance as determined through review of standardized evaluations completed during fellowship training mapped to the Accreditation Council for Graduate Medical Education (ACGME) Infectious Disease Milestones.
In conclusion, this study of a relatively large academic training program in ID observed several variables that were associated with academic success during fellowship training and short-term outcomes after graduation from the ID fellowship training program.

Table 1 .
Pre-fellowship characteristics of 39 infectious diseases Fellows.
Abbreviations: USMLE, United States Medical Licensing Examination.a Data are N (%) unless otherwise specified.

Table 2 .
Intra-fellowship and post-fellowship characteristics of 39 infectious diseases Fellows .
Abbreviations: ITE, In-Training Examination; US, United States; USMLE, United States Medical Licensing Examination.a Data are N (%) unless otherwise specified.

Table 3 .
Associations between demographic factors and pre-fellowship Variables.
Abbreviations: ITE, In-Training Examination; US, United States; USMLE, United States Medical Licensing Examination; CK, Clinical Knowledge; LOR, Letter of Recommendation.a Data are N (%) unless otherwise specified.

Table 4 .
Associations between pre-fellowship and In-fellowship Variables .

Table 5 .
Associations between In-fellowship variables and Outcomes .
Abbreviations: ITE, In-Training Examination.a Data are N (%) unless otherwise specified.